Kidney Transplant Services
Table of Contents
- Kidney Transplant Services
- Physician Services
- Pretransplant Services
- Immunosuppressive Drugs
- Cadaver Donor
- Updated CMS-1500 Claim Form Guidelines
Kidney Transplant Services
Medicare covers kidney transplant services under the ESRD program. The transplant service is a process by which a kidney is excised from a live donor and then implanted in an ESRD patient. Supportive care is furnished to the living donor and to the recipient following the transplant. Reimbursement for kidney transplant surgery will be made only if the surgery is performed in a renal transplant center approved under the federal, state, and local regulations. The medical facility must meet special health, safety, professional and staffing standards directly related to the kidney transplant services.
When billing for services associated with the live kidney donation, modifier Q3 (Live kidney donor surgery and related services) should be reported on the CMS-1500 claim form.
Physician Services
Physician services furnished to live kidney donors must be paid at 100 percent of the allowed charge as required by Section 1881(d) of the Social Security Act. The Q3 modifier must be used so that a kidney donor is not charged the co-payment amount which would otherwise apply (since Medicare usually pays 80 percent of the allowed charge under the Medicare physician fee schedule).
Pretransplant Services
Pretransplant costs related to the evaluation and testing of living donors for transplants are payable under Medicare, but must be billed to the certified transplant center. The costs are accumulated in the certified transplant center's acquisition cost centers and are reimbursed through Part A (i.e., billed to the fiscal intermediary). Only those physician costs incurred when the donor is admitted to the hospital for the actual surgery (i.e., donor nephrectomy) and the costs incurred for postoperative care directly related to the surgical procedure may be billed to Medicare through the Part B carrier.
Similarly, charges for electrocardiograms, cardiac ultrasound, X-rays, laboratory, and other tests to preoperatively evaluate the living donor must be billed to—and the provider reimbursed by—the certified transplant center directly; they should not be billed to the Part B carrier
Immunosuppressive Drugs
Medicare covers immunosuppressive drugs, such as cyclosporine, furnished to an organ transplant recipient for up to one year after the date of the transplant. Coverage is limited to those immunosuppressive drugs that specifically are labeled and approved for marketing as such by the FDA. Also included are prescription drugs, such as prednisone, that are used in conjunction with immunosuppressive drugs as part of the therapeutic regimen. Drugs not directly related to rejection control, such as antibiotics and hypertensive medications, are not covered under this benefit. Medicare will pay for immunosuppressive drugs that are provided outside the one-year limit if the drugs are covered under some other provision of the law (e.g., when the drugs are covered as inpatient hospital services or are furnished incident to a physician’s service).
Cadaver Donor
Removal of kidneys from a deceased person for transplant purposes is usually furnished by an organ procurement agency or laboratory and therefore will be denied with the message, “The facility must bill the claim to be considered under the Medicare program.”
Updated CMS-1500 Claim Form Guidelines
- Recipient name in Item 2
- Recipient address in Item 5
- Recipient Medicare number in Item 1a
Additional ESRD information can be accessed in the CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 8, Sections 120 and 140.
Reviewed 8/28/2024